Mh C&p In, Some Questions About Symptoms Noted Vs. Progress Notes

[brokensoldier244th]

I got my MH C&P notes back today, and as I peruse them I don't see too much that is glaringly off until I get to the "Symptoms" section in Section II, Clinical notes. Under the list of symptoms, only Depressed Mood is marked [X]. Nothing about disturbances of motivation or mood, disturbances of sleep, mild memory loss-things that are in my treatment notes with my Psychologist. Under the "Occupational Social Impairment" section he checked: "Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self care and conversation".

Tossing and turning, mind-mapping to keep thing straight, and my lack of motivation for social settings is noted in the write up under "current mental health", though. I just hope that stuff typed out in block gets read, too, and not just the things that are 'X'd off.

It also bothers me a bit that the diagnosis code is "MDD, Severe, Single Episode" (296.23) when my normal treatment notes from early April to present designate it as recurrent. How does a rater take that and run with it?

Is it normal for there to only have 1 thing marked in that entire symptoms section, even though the instructions state to check any and all symptoms related to the diagnosis? The rating isn't just based off of the checklist, is it? They will look at my psych notes,etc as well, where these things are noted? I thought the C&P was to take that into account in their overall write up, summarizing it, if you will, but maybe not. Is there going to be any weirdness with having only a single GAF when my clinician uses SOAP style notes with no GAF scores? (thus, no pattern)

My Axis(s) were listed as:

Axis IDiagnosis-Major Depresive Disorder, Moderate, with Obsessive Compulsive tendencies (not full blown disorder)ICD Code 296.23 (Major Depressive Disorder, Severe, single episode)

Diagnosis 2 (none)

Axis II Nothing listed

Axis III Medical diagnois-C&P records

Axis IV

Service related lumbar spine and sciatic nerve

GAF score 58

"There is no history of mental health hospitalization. The veteran was started on Sertraline by the physician initially for PME and then over time he started taking that daily for his mood, 1/2 tab daily"

"The veteran is married, 4 children. The veterans wife is employed as asst. manager of a movie theater. The veteran noted that often times they watch DVR or rental movies for family activity. The veteran noted that usually after the new movies have been out a few weeks they are more likely to do to movies when there will be less of a crowd."The veteran noted that his children are involved in [activities] and that he is involved, his wife does the majority of those activities."

"The veteran noted that Sertraline has calming effect upon his emotions and thought process. The veteran noted that he has been trying to work on physical prowess by exercising but that Physical Therapy said he was working too hard and in a manner that would not be conducive to reduction in pain. The veteran has avoided narcotic pain medication as he does not want to further dull his faculties. the veteran does not that there are times where he does not have an appetite and forgets to eat. The veterans energy level has been low to poor. The veteran noted that he will "mind map" to keep his clientele straight. The veteran has difficulty getting comfortable at night. The veteran tosses and turns repeatedly during the night. The veteran noted that he tends to be regimented and structured so as to try to contain the depressive symptomology.

The veteran noted that hsi sex drive is "not really...we cuddle, we dont' have sex......I take drugs for it, but then I don't 'want to'....". The veteran does not feel hopeless-he says that is why he sees his psychologist. the veteran does have some time he feels helpless. The veteran knows that his back pain "is going to be a lifetime thing. I get sick of it...i get tired of it hurting...i get tired of people asking why I don't spend time with them or do things with them... because there are days i can't get off the couch."

The veteran has friends "and we do things sometimes, my close friends understand most of the time. Acquaintances feel like I am a buzz kill". The veteran is not suicidal nor homicidal. Th vetera's mood is depressed daily nearly every day or all day, he describes difficult concentrating at home and at work."

Edited August 29, 2011 by brokensoldier244th

[Hoppy]

I am of the opinion that the C&P examiners are required to opine on the cause of depression in a case like yours. I had planned on digging up the work sheet to see what it says before reading your recent post. I am working on a position paper. Whether or not the work sheet requires an opinion on etiology the VA wouild be required to seek such an opinion. The entire issue of whether or not your depression is related to your back should not have remained silent at the time of a decision. If the record is silent the claim was not properly developed.

I believe that the nexus should be addressed with full supporting logic whether the nexus is favorable or not. The C&P examiner should not be allowed to ignore an issue. The examiner would need to provide supporting rational for his diagnosis of a single episode and why the references in your treatment records which you believe link your depression to your back were not considered.

I will have more to say later. I just realized I was typing this on the board. I would rather type this up in word then pate it to the board.

[Hoppy]

CAS,

This is a continuation of my previous post.

This is the long version of the issues involved in your claim. The first thing I want to point out is that I have discussed this type of claim with several VA staff psychologists including the Chief of Psychiatry at a VAMC.

My training includes; formal training in psychology at a major university, advanced training on how to develop Workman’s Compensation claims at the American Institute of Specialized Studies and instruction from an MD/JD that all injuries have resultant secondary comorbid psychological symptoms that the claimant most be screened for. These secondary psychological symptoms can resolve over time. Sometimes they do not resolve. In any event before the doctors I worked with signed off a claim this issue was addressed. I am amazed that the VA does not routinely screen injured veterans for secondary psychological considerations and require that they be addressed on all claims. I guess the difference is that the doctors I worked with under labor law were truly advocates for the injured worker.

The fact that your claim has advanced to the decision phase without this issue being specifically identified and addressed with supporting logic in favor of or against service connection is an aberration to someone with my training. The fastest way to deal with this is to get a medical opinion from either a VA treating clinician or a private clinician. In either case they must meet the requirement the VA has for mental health examiners. Appealing on the basis that the C&P was inadequate could delay the claim for years. However, making such an appeal as soon as possible is recommended in the event they have some way of fast tracking a new exam. A veteran who posted on hadit claimed he brought up the issue of an inadequate exam with the director of the VAMC and received a new exam in a very short period of time. I would recommend talking to your treating clinicians, filing an appeal and talking to the director of the VAMC. When advancing a claim, surrounding the VA is the best way to keep your claim from falling through the cracks in the system.

Back to the VA staff clinicians. This is what I was taught by the VA psychologists. When evaluating secondary psychological symptoms due to medical conditions the level of psychological symptoms must be considered an “overreaction”. Over reactions are identified by behavior patterns that are the product of excessive “guarding”. For instance, an individual with a lower back problem is released by the treating medical doctor and the individual refuses to seek work because they are afraid that they will re-injure their back. This psychological reaction can be short term or long term. The length of this type of reaction is hard to predict.

Different clinicians will throw different diagnoses at these individuals. Depression and anxiety disorders are very common. It is my experience that VA clinicians will use depression and anxiety disorders. This is what occurred in the BVA case that I sent you in which the veteran was awarded service connection for a psychological condition due to their back injury. Even in view of VHA directive 2008-71, I see nothing prohibiting a treating VA clinician from making a diagnosis of an anxiety disorder or mood disorder due a medical condition or secondary to a medical condition if it is the most accurate diagnosis of your condition and providing supporting logic justifying the diagnosis. I have obtained this type of report from VA treating clinicians for other veterans.

If your treatment records show that you are depressed due to your pain, I am not sure this would result in a separate “overreaction”. Everybody is depressed by pain. However, if your treatment records show that there are specific behaviors that are considered “overreactions” and these behaviors result in a long period of decreased social or occupational function, then a psychological diagnosis would be appropriate. I have not found a specific time requirement for a secondary psychological condition. However, I would argue it would be the same as required by the DSM IV for a diagnosis of an anxiety or mood disorder without a comorbid medical condition. Having this spelled out in the treatment records would benefit your claim. However, I have seen C&P examiners simply make the diagnosis without any supporting logic and the claim was awarded. This is especially true when the C&P examiner is a VA staff clinician who the VBA has been seeking opinions from for many years.

Some veterans have told me they benefited by having their treating clinicians read my letters.

[john999]

When I have gotten IMO's in the past I explain to the doctor just exactly what I am trying to accomplish. It is up to them to concur or differ. For instanance, because I have chronic pain due to SC condition I explain the reasons and symptoms of my depression and let them make the obvious conclusion. I am paying them so I drive a hard bargain. In years past I had a VA PCP that was very cooperative. She wrote the best medical opinions I have ever seen. She was a Russian and as smart as a whip. She knew the system.

[brokensoldier244th]

im still in development right now. DAV guy says he has it to a rater, but that was just the other day. My treatment thus far has been ongoing for 5 months, but I was injured in 2001 and discharged in 2002 for a trauma (lower back/fall/injury) and im currently rated at 40% for that, and 10% for extremity radiculopathy. I really like my therapist and she and I talked yesterday about her providing a prognosis/duration statement but she swears by the directive and said she talked to her supervisor as well to get an idea of her boundaries. Are raters required to look for the 'magic words' of "is likely, is as likely as not," etc, or can they address the record as a whole? She has noted that I am seeing her for pain, as does the C&P guy, but they don't say it with the phrase du jour. Being that im in Development/rating right now, im in the worst possible time to be worrying about this, and I don't see her again until the 7th (about every 3-4 weeks). im just worried that there isn't enough to go on, that the disparity between the Examiners diagnosis of "single occurrence" vs her diagnosis of "recurrent" will reflect badly in some way on me. Does "single occurrence (296.23 ICD) mean something different than I would interpret it to mean?

Thank you for your explanation of things.

CAS,

This is a continuation of my previous post.

This is the long version of the issues involved in your claim. The first thing I want to point out is that I have discussed this type of claim with several VA staff psychologists including the Chief of Psychiatry at a VAMC.

My training includes; formal training in psychology at a major university, advanced training on how to develop Workman's Compensation claims at the American Institute of Specialized Studies and instruction from an MD/JD that all injuries have resultant secondary comorbid psychological symptoms that the claimant most be screened for. These secondary psychological symptoms can resolve over time. Sometimes they do not resolve. In any event before the doctors I worked with signed off a claim this issue was addressed. I am amazed that the VA does not routinely screen injured veterans for secondary psychological considerations and require that they be addressed on all claims. I guess the difference is that the doctors I worked with under labor law were truly advocates for the injured worker.

The fact that your claim has advanced to the decision phase without this issue being specifically identified and addressed with supporting logic in favor of or against service connection is an aberration to someone with my training. The fastest way to deal with this is to get a medical opinion from either a VA treating clinician or a private clinician. In either case they must meet the requirement the VA has for mental health examiners. Appealing on the basis that the C&P was inadequate could delay the claim for years. However, making such an appeal as soon as possible is recommended in the event they have some way of fast tracking a new exam. A veteran who posted on hadit claimed he brought up the issue of an inadequate exam with the director of the VAMC and received a new exam in a very short period of time. I would recommend talking to your treating clinicians, filing an appeal and talking to the director of the VAMC. When advancing a claim, surrounding the VA is the best way to keep your claim from falling through the cracks in the system.

Back to the VA staff clinicians. This is what I was taught by the VA psychologists. When evaluating secondary psychological symptoms due to medical conditions the level of psychological symptoms must be considered an "overreaction". Over reactions are identified by behavior patterns that are the product of excessive "guarding". For instance, an individual with a lower back problem is released by the treating medical doctor and the individual refuses to seek work because they are afraid that they will re-injure their back. This psychological reaction can be short term or long term. The length of this type of reaction is hard to predict.

Different clinicians will throw different diagnoses at these individuals. Depression and anxiety disorders are very common. It is my experience that VA clinicians will use depression and anxiety disorders. This is what occurred in the BVA case that I sent you in which the veteran was awarded service connection for a psychological condition due to their back injury. Even in view of VHA directive 2008-71, I see nothing prohibiting a treating VA clinician from making a diagnosis of an anxiety disorder or mood disorder due a medical condition or secondary to a medical condition if it is the most accurate diagnosis of your condition and providing supporting logic justifying the diagnosis. I have obtained this type of report from VA treating clinicians for other veterans.

If your treatment records show that you are depressed due to your pain, I am not sure this would result in a separate "overreaction". Everybody is depressed by pain. However, if your treatment records show that there are specific behaviors that are considered "overreactions" and these behaviors result in a long period of decreased social or occupational function, then a psychological diagnosis would be appropriate. I have not found a specific time requirement for a secondary psychological condition. However, I would argue it would be the same as required by the DSM IV for a diagnosis of an anxiety or mood disorder without a comorbid medical condition. Having this spelled out in the treatment records would benefit your claim. However, I have seen C&P examiners simply make the diagnosis without any supporting logic and the claim was awarded. This is especially true when the C&P examiner is a VA staff clinician who the VBA has been seeking opinions from for many years.

Some veterans have told me they benefited by having their treating clinicians read my letters.

Edited August 25, 2011 by brokensoldier244th

[Hoppy]

To clarify, I do not feel the C&P exam presented any significant evidence against your claim. The problem is that the nexus question is the question that is formated to include "more likely than not", "as likely as not" and less likely than not" related to your back condition. The C&P examiner did not offer an opinion. The single episode of depression can be totally unrelated to the recurrent depression your treating doctor is talking about. The code the C&P examiner used is not even a DSM IV code. 296.23 ICD refers to the international classification of diseases (ICD). The VA is required to use the DSM IV when adjudicating a claim. What you need is a diagnosis of a psychiatric condition due to or secondary to a service connected medical condition. I can not tell your treating doctor she has to make a diagnosis. However, I have in fact had VA clinicians make such a diagnosis without even asking for it. A proper and full diagnosis would be beneficial. It is still possible the raters will be forced to throw out the C&P because he used the ICD code. Then the notes from the treating clinician without a specific diagnosis of a psychiatric condition due to the service connected condition would require that the raters connect some dots. I do not count on raters connecting the dots. Like John said, get the doctors to put in the report exactally what will make it clear to the raters your condition is.

Edited August 25, 2011 by Hoppy

[brokensoldier244th]

296.23 in DSM IV = Severe without psychotic features

Maybe he meant that....but.......here we are again with the ambiguous C&P

*sigh* Thanks for bearing with me on this Hoppy. I typed up almost all the C&P. Ill comb through it again, but nothing jumped right out at me that said "A=B or A/=B". He was a contracted Psychologist that normally does troubled teens in a secure facility, but you'd think that he would know what he was supposed to do. My treating doctor has listed me in here SOAP notes as "Major depression, Moderate, Recurrent" every time we've met since May, if that helps. Hopefully I don't come across as stalkerish or weird, but I found his practice and I faxed him today with my concerns about there not being a yea/nay statement. We'll see what he says, if anything.

Attached is what I faxed him. I hope it doesn't sound stalkerish, or that im not breaking some cardinal rule. I assumed since he saw me for my exam that I could contact him as a patient.

To clarify, I do not feel the C&P exam presented any significant evidence against your claim. The problem is that the nexus question is the question that is formated to include "more likely than not", "as likely as not" and less likely than not" related to your back condition. The C&P examiner did not offer an opinion. The single episode of depression can be totally unrelated to the recurrent depression your treating doctor is talking about. The code the C&P examiner used is not even a DSM IV code. 296.23 ICD refers to the international classification of diseases (ICD). The VA is required to use the DSM IV when adjudicating a claim. What you need is a diagnosis of a psychiatric condition due to or secondary to a service connected medical condition. I can not tell your treating doctor she has to make a diagnosis. However, I have in fact had VA clinicians make such a diagnosis without even asking for it. A proper and full diagnosis would be beneficial. It is still possible the raters will be forced to throw out the C&P because he used the ICD code. Then the notes from the treating clinician without a specific diagnosis of a psychiatric condition due to the service connected condition would require that the raters connect some dots. I do not count on raters connecting the dots. Like John said, get the doctors to put in the report exactally what will make it clear to the raters your condition is.

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Edited August 25, 2011 by brokensoldier244th